European Journal of Cardiovascular Medicine

Clavicle fractures are common orthopaedic injuries, accounting for 2.6% to 5% of all fractures, and they involve the middle third of the clavicle in up to 82% of fractures1-3 . Traditionally, these fractures were managed nonoperatively after early studies reported that conservative treatment led to a high union rate without compromise of patient satisfaction or function.4,5 However, more recent literature has shown increased rates of nonunion, symptomatic malunion, and unsatisfactory patient outcomes with nonoperative management of displaced midshaft clavicle fractures.6-9 The incidence of clavicle fractures caused by high energy trauma is increasing and may contribute to these findings because increased initial fracture displacement, shortening, and comminution have been shown to be predictive of nonunion and poor patient outcomes with nonoperative care.10,11 Consequently, there has been an increase in operative fixation of displaced midshaft clavicle fractures. Numerous clavicle fixation methods exist, but plate and screw constructs lead to predictable outcomes with a low non-union rate.7,8 Currently, two methods of clavicle plating are used, in which a plate is contoured to either the superior or anteroinferior surface of the clavicle. Regardless of placement, the subcutaneous position of the plate may induce implant prominence and scar related pain after fracture union, which may lead to patient requests for implant removal.12

The most common benefit of antero-inferior plating is that it avoids the most superficial, superior aspect of the clavicle and is hypothesized to reduce complaints associated with implant prominence.13-15 In addition, drilling and screw placement in an anteroinferior to posterior direction is thought to reduce risk to the underlying neurovascular bundle while also allowing the use of longer screws due to the larger anteroinferior to posterior diameter of the clavicle.13,16 However, the commonly accepted concept of increased safety with antero inferior plating has been questioned in several recent studies that reported that the risk of iatrogenic neurovascular injury is possible regardless of plate position.17,18 Other recent studies have focused on the biomechanical properties of these two plating methods found varying results. One initial biomechanical comparison revealed that over-all improved mechanical stability with the use of a superior plate.19 However, newer literature has shown advantages to both plating methods depending on the type of stress being exerted on the clavicle.20,21

Aim & Objectives:

AIM: To Compare the outcomes of surgically managed displaced middle1/3rd shaft clavicular fractures by superior versus anteroinferior plating.

A prospective comparative study done at the department of Orthopaedics, Guntur medical college / GGH Guntur on 30 patients who had displaced middle 1/3rd clavicle fractures and met the selection criteria. This study includes both male and female patients with displaced middle 3rd clavicle fractures, treated with superior versus anteroinferior plating during the period from February 2022 to February 2024.

Routine investigations were done for all the patients. All patients were evaluated clinically and radiologically to assess for any other injuries. Radiographs were taken in two planes, AP and Lateral views. Patients were operated as early as possible. Over the period of study in which 30 patients were operated, the patients are grouped into two. One group with 16 patients were operated with open reduction and internal fixation with superior plate osteosynthesis (contoured reconstruction plate) and another group with 14 patients were operated with open reduction and internal fixation with anteroinferior plating.

 Inclusion Criteria:

a. Displaced middle third clavicle fractures (Robinson type IIb)

b. Patients of 20-60 years of age.

c. Patients who are fit for surgery, willing for treatment and given written informed consent.

Exclusion Criteria:

a. Patients with undisplaced clavicle fractures.

 b. patients with proximal or distal 3rd fractures.

c. Open clavicle fractures.

d. Old age debilitated patients.

e. Patients unfit for anaesthesia.

f. Patients not willing for surgery.

The patients were followed up 1 month, 3months and 6 months postoperatively and clinical and radiological union are assessed.

Operative Technique for Plating:

Under General anaesthesia/regional block with patient in Supine position with sand bag in the inter scapular region. Operative site including the arm was prepared and draped so that it can be intraoperatively mobilized and used as a reduction aid. A curvilinear incision along the superior surface of clavicle was made. The platysma was divided to expose the periosteum. Minimal dissection of periosteum was done to expose the fracture. The fracture ends were distracted and the fracture reduction was done. Temporary fixation with k wires are done if necessary. Appropriate plate selected and bending was done using the plate benders. Plate was positioned over superior surface or anteroinferior surface of the reduced bone held with plate holding forceps and fixed with minimum of 3 screws on either side. Haemostasis achieved and closure done is layers, Sterile dressing was applied. Suction drain not applied for any case. Arm sling was applied for protection and to minimize the operative site pain.

Postoperative Care and Rehabilitation:

The post op protocol for both group of patients are same. The arm is not elevated above 120 degrees in any plane till 4 weeks post-operative period. The arm was maintained in a sling on a full-time basis for two weeks. The patients are instructed not to lift objects > 2 kg in the operated side for 6 weeks. Ice fomentation 3-5 times (15 minutes each time) per day is adviced to control swelling and inflammation. The patients are encouraged to maintain good upright shoulder girdle posture.

1 st Week: Exercises (3x per day)

Pendulum exercises.

Ball squeezing exercises.

 Isometric exercises of rotator cuff external and internal rotations with arm by the side are started.

Isometric shoulder abduction, adduction, extension and flexion with arm at side are started.

Weeks 2 - 4: Suture removal done on 12^th post operative day.

Soft-tissue treatments for associated shoulder and neck musculature for comfort. Gentle pulley for shoulder ROM 2x/day.

Weeks 4 - 8:

Mid-range of motion rotator cuff external and internal rotation exercises started.

Active and light resistance exercises (through 75% of ROM as patient’s symptoms permit) without shoulder elevation and avoiding extreme end ROM.

Weeks 8 - 12:

 Full shoulder Active ROM in all planes.

Increase manual mobilizations of soft tissue as well as glenohumeral and scapulothoracic joints for ROM.

No repeated heavy resisted exercises or lifting until 3 months.

Weeks 12 and beyond:

 More aggressive strengthening program as tolerated were started.

 Increase the intensity of strength and functional training for gradual return to activities and sports.

After clinical and radiological union, most patients were allowed to participate in sports activities usually by three to four months.

All the patients were reviewed on 2nd week, 4th week and then every monthly for the next three months and there after once in three months. During follow up, patients were clinically evaluated for pain, activities of daily life, range of movements of shoulder joint and power.

Radiological evaluation of the union was done by taking serial x-rays. Radiological union was taken to be achieved when there is bridging trabeculations across the fracture on three of four cortices at the fracture line. Any changes in the previous alignment, screw pullout or implant failure also noted.

Functional outcome was based on the Quick DASH scoring system.

A prospective comparative study done at the department of Orthopaedics, Guntur medical college / GGH Guntur on 30 patients who had displaced middle 1/3rd clavicle fractures and met the selection criteria. This study includes both male and female patients with displaced middle 3rd clavicle fractures, treated with superior versus anteroinferior plating during the period from February 2022 to February 2024.

Routine investigations were done for all the patients. All patients were evaluated clinically and radiologically to assess for any other injuries. Radiographs were taken in two planes, AP and Lateral views. Patients were operated as early as possible. Over the period of study in which 30 patients were operated, the patients are grouped into two. One group with 16 patients were operated with open reduction and internal fixation with superior plate osteosynthesis (contoured reconstruction plate) and another group with 14 patients were operated with open reduction and internal fixation with anteroinferior plating.

 Inclusion Criteria:

a. Displaced middle third clavicle fractures (Robinson type IIb)

b. Patients of 20-60 years of age.

c. Patients who are fit for surgery, willing for treatment and given written informed consent.

Exclusion Criteria:

a. Patients with undisplaced clavicle fractures.

 b. patients with proximal or distal 3rd fractures.

c. Open clavicle fractures.

d. Old age debilitated patients.

e. Patients unfit for anaesthesia.

f. Patients not willing for surgery.

The patients were followed up 1 month, 3months and 6 months postoperatively and clinical and radiological union are assessed.

Operative Technique for Plating:

Under General anaesthesia/regional block with patient in Supine position with sand bag in the inter scapular region. Operative site including the arm was prepared and draped so that it can be intraoperatively mobilized and used as a reduction aid. A curvilinear incision along the superior surface of clavicle was made. The platysma was divided to expose the periosteum. Minimal dissection of periosteum was done to expose the fracture. The fracture ends were distracted and the fracture reduction was done. Temporary fixation with k wires are done if necessary. Appropriate plate selected and bending was done using the plate benders. Plate was positioned over superior surface or anteroinferior surface of the reduced bone held with plate holding forceps and fixed with minimum of 3 screws on either side. Haemostasis achieved and closure done is layers, Sterile dressing was applied. Suction drain not applied for any case. Arm sling was applied for protection and to minimize the operative site pain.

Postoperative Care and Rehabilitation:

The post op protocol for both group of patients are same. The arm is not elevated above 120 degrees in any plane till 4 weeks post-operative period. The arm was maintained in a sling on a full-time basis for two weeks. The patients are instructed not to lift objects > 2 kg in the operated side for 6 weeks. Ice fomentation 3-5 times (15 minutes each time) per day is adviced to control swelling and inflammation. The patients are encouraged to maintain good upright shoulder girdle posture.

1 st Week: Exercises (3x per day)

Pendulum exercises.

Ball squeezing exercises.

 Isometric exercises of rotator cuff external and internal rotations with arm by the side are started.

Isometric shoulder abduction, adduction, extension and flexion with arm at side are started.

Weeks 2 - 4: Suture removal done on 12^th post operative day.

Soft-tissue treatments for associated shoulder and neck musculature for comfort. Gentle pulley for shoulder ROM 2x/day.

Weeks 4 - 8:

Mid-range of motion rotator cuff external and internal rotation exercises started.

Active and light resistance exercises (through 75% of ROM as patient’s symptoms permit) without shoulder elevation and avoiding extreme end ROM.

Weeks 8 - 12:

 Full shoulder Active ROM in all planes.

Increase manual mobilizations of soft tissue as well as glenohumeral and scapulothoracic joints for ROM.

No repeated heavy resisted exercises or lifting until 3 months.

Weeks 12 and beyond:

 More aggressive strengthening program as tolerated were started.

 Increase the intensity of strength and functional training for gradual return to activities and sports.

After clinical and radiological union, most patients were allowed to participate in sports activities usually by three to four months.

All the patients were reviewed on 2nd week, 4th week and then every monthly for the next three months and there after once in three months. During follow up, patients were clinically evaluated for pain, activities of daily life, range of movements of shoulder joint and power.

Radiological evaluation of the union was done by taking serial x-rays. Radiological union was taken to be achieved when there is bridging trabeculations across the fracture on three of four cortices at the fracture line. Any changes in the previous alignment, screw pullout or implant failure also noted.

Functional outcome was based on the Quick DASH scoring system.

Clavicle fractures, one of the common fractures of adult population are often treated conservatively since the time of Hippocrates. Thorough understanding of the musculoskeletal anatomy and the dynamic relation between clavicle and shoulder motion is essential in management of clavicle fractures. The deforming forces, the degree of comminution and overriding causes shortening of the clavicle. Shortening more than 2 cms influences the outcome in the midshaft clavicle fractures.

 In clavicle fractures, the major determining factor for restoration of function of upper limb is the restoration of clavicular length. As early as 1790, Therselben described that the chief function of clavicle is to keep the shoulder blade away from the axial skeleton which helps in proper functioning of the shoulder. His postulates were confirmed by many studies with the restoration of clavicular length after surgery resulted in better functional outcome

For a long period of time clavicle fractures were traditionally managed conservatively. There was unanimous thought to leave these fracture conservatively with a simple sling or figure of 8 bandage. Based on review of various recent studies on the management of clavicle fractures by conservative methods, the effectiveness of non-operative management is found to be deficient in providing optimal outcome particularly in young population and had unsatisfactory results.

Recent studies suggest that the operative management of middle third clavicle fractures resulted in lower non union rates, improved functional outcome, faster mobilization, better cosmesis and increased patient satisfaction. Operatively, clavicle fractures are commonly managed either with plate osteosynthesis or intramedullary elastic nailing. It becomes imperative for a surgeon to know the various aspects of plating and nailing and also their advantages and disadvantages to make a proper choice of surgery. Theoretically, both plate osteosynthesis and titanium nailing have their own advantages. A biomechanical study suggest that plate fixation results in more rigid fixation when compared to nailing and this helps in having an early rehabilitation. Plate fixation is technically easy to perform and provides rotational control. Disadvantages include large wound size and implant prominence.

According to recent studies, comparision of the clinical results of mid shaft clavicular fracture in patients Among the surgical methods used by orthopaedic surgeons for the treatment of mid shaft clavicular fractures, plate fixation continues to be the most popular because of its safe and reliable outcomes. However, the optimal surgical approach for plating of mid shaft clavicular fractures remains controversial. The study conducted demonstrated the safety of both the anteroinferior and superior approaches for treating displaced mid shaft clavicular fractures in patients using a plate fixation. While both approaches are seen as safe and clinically successful, the advantages of the anteroinferior plating method over the superior approach include shorter operative time, less blood loss and fewer implant associated complications. The Quick DASH scores were significantly lower in the anteroinferior plated group than in the superiorly plated group at 3 months postoperatively; however, there was no significant difference between groups regarding the scores at final follow-up. Additionally, a significantly greater proportion of the anteroinferiorly plated group was able to resume previous activities of daily living within 3 months postoperatively compared with the superiorly plated group. Pai et al.16 reported on midclavicular fractures in 35 patients with an average age of 66.3 years treated with a nonlocking plate (superiorly plated) and found there was one case of nonunion (2.9%) and four cases of plate loosening (11.4%). Lee et al.9 also reported on mid-clavicular fractures in 30 patients with a mean age of 56.7 years treated with a nonlocking plate (superiorly plated) and found there was one case of nonunion (3.3%) and two cases of implant failure (6.7%). The major complication in the study by Lee etal.9 was plate and screw loosening due to poor bone quality. In our study, nonunion was not found in either group However, there were no cases of malunion, two case of implant prominence (12.5%) in the superiorly-plated group. In contrast, there was no malunion or implant failure in the anteroinferiorly-plated group. These findings parallel the reports of recent biomechanical studies and highlight the advantages of the anteroinfer-ior approach to treatment. Partalet al.17 found that anteroinferior placement of the reconstruction plate provides a more stable construct in bending rigidity compared with plates placed superiorly. Favre et al.18 reported that anteroinferior placement of the reconstruction plate induced deformation modes similar to the intact clavicle, while superior placement of the reconstruction plate induced deformation modes that were non-physiological, indicating that anteroinferior placement was less likely to fail during normal physiological loading. We believe that anteroinferior placement of the reconstruction plate can provide more rigid fixation, which will minimize fixation failure. 30 cases of displaced middle third clavicle fractures were evaluated at GGH, Guntur of which 16 patients are treated with superior plating and another 14 patients with anteroinferior plating.

The incidence of fixation failure and rate of nonunion, whether anteroinferiorly  or superiorly plated, was lower in this study than in previous studies. This could potentially be explained relatively by conservative rehabilitation program. The optimal duration of postoperative immobilization for clavicular fracture is controversial, with the literature recommending postoperative immobilization for 2 to 6 weeks, we chose to implement an immobilization period of 4 to 6 weeks, compared with previous studies that implemented immobilization periods of 1 to 2 weeks22 and 2 to 4 weeks23.  The incidence of fixation failure was lower in this study due to the longer immobilization time. In addition to rehabilitation protocol, we consider that lower rate of fixation failure could be due to conventional anti osteoporosis treatment given to patients with BMD loss. While BMD was not measured at final followup, it is assumed that the patients‟ bone quality improved after anti-osteoporosis treatment, which could have led to a decrease in the incidence of fixation failure. Finally, in cases of comminuted fractures, autologous bone grafting from the iliac crest was used to minimize the risk of nonunion.

The results indicate that the anteroinferior plating method was accompanied by no cases of implant prominence compared with the superior plating approach. Similarly, Formainiet al.24 compared anteroinferior plating with superior plating of displaced mid shaft clavicular fractures and found that superior plating led to an increased rate of patient reported implant prominence and prompted more requests for implant removal. With regard to operative time, we found that the anteroinferiorly plated group required less time than the superiorly-plated group. There are two possible explanations for this result. In the supine position, the anteroinferior aspect of the clavicle is located in the centre of the surgical field, which is more convenient for surgery. Second, in the anteroinferiorly plated group, the screws are safely directed posterosuperiorly, away from vulnerable infraclavicular structures, which reduces the surgeon‟s concerns regarding iatrogenic injury and saves time. Also, the anteroinferiorly plated group had less operative blood loss than the superiorly plated group. Understandably, less blood loss is associated with shorter operative time, and it is believed that shorter operative time and less operative blood loss reduce the overall risks of surgery and anaesthesia. Based on the functional outcome at 6 months, In superior plating group, we had 9 patients with excellent outcome,6 patients with good outcome and 1 patient with poor outcome. In anteroinferior plating group 10 patients with excellent outcome, 4 patients with good outcome.

This study has limitations. First of all the number of cases is small, and the study was done at a single centre. This study is a prospective and not a randomised control study. Further this study involves limited number of subjects. Therefore statistical significance of this study can be questioned. However this study shows some basic information comparing superior plating and anteroinferior plating for clavicle fractures. This study supports further randomised control trials and with a large number of samples to arrive at a definite conclusion.

Traditionally clavicle fractures were managed nonoperatively. However, recent literature has shown increased rates of nonunion, symptomatic malunion, and unsatisfactory patient outcomes with nonoperative management of displaced mid shaft clavicle fractures. Consequently, there has been an increase in operative fixation of displaced midshaft clavicle fractures. Currently, two methods of clavicle plating are used, in which a plate is contoured to either the superior or antero-inferior surface of the clavicle. While both anteroinferior and superior plate placement are safe and effective for displaced midclavicular fractures patients, the anteroinferior approach involves less complications and implant prominence, and enables faster return to normal activities

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18.    Lo EY, Eastman J, Tseng S, Lee MA, Yoo BJ. Neurovascular risks of anteroinferior clavicular plating. Orthopedics. 2010;33:21. 

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Formaini N, Taylor BC, Backes J, et al. Superior versus anteroinferior plating of clavicle fractures. Orthopedics. 2013;36:e898-e904.